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Infection-1 2010/11 EUKARYOTIC PARASITES OF HUMANS PROTOZOA- TISSUE COCCIDIA Objectives To be able to Name and state the habitats of tissue coccidia that cause human disease State the source (s) of infection, entry to and exit of agent from humans Describe the life cycle with stages and events Identify the stages that cause pathogenic effects Outline laboratory methods of identification of organism Identify points in the life cycle where preventive measures are applicable Describe the pathogenicity List the clinical features Describe transmission, prevention and control of toxoplasmosis INTRODUCTION The coccidian sporozoa invades and reproduces in epithelial cells, usually of the intestinal tract. Some undergo both asexual and sexual replication in one host and others, while undergoing sexual reproduction in the intestinal epithelial cells of one host, undergo asexual multiplication in tissues of a wide variety of hosts.

Toxoplasma gondii is the most important of the coccidian parasites of humans.

Toxoplasma gondii is an intracellular parasite that infects most mammals worldwide. Human infection is usually mild or asympatomatic. However, it is a major infective disease of the foetus causing congenital infection and also causes life-threatening disease in the immunocompromised patient. It is a coccidian parasite, which has a sexual reproduction in the intestinal epithelium of the cat and asexual reproduction in a wide variety of intermediate hosts such as birds, rodents and mammals including humans. Geographical distribution: The parasite is widely distributed throughout the world. Infections have been reported in Sri Lanka. Location in host: In humans, in the acute stage trophozoites (Zoites) are found in macrophages and lymphoid tissues. In the chronic stage the zoites are found inside true cysts in various organs but particularly in brain and eye. Morphology: There are three morphological forms of parasite (1) Trophozoites( zoites) and pseudocyst- these are cresentic in shape with pointed ends and measure 4 8 m. Zoites are found in macrophages ( pseudocysts) and other nucleated cells. They multiply intra cellularly by a process called endodyogeny (internal budding). These zoites are also known as tachyzoites due to their rapid multiplication. The pseudocysts (macrophages containing tachyzoites) are able to cross the placenta into the foetus. (2) bradyzoites and true cysts- These are tissue cysts that can be found in visceral organs including lungs, liver and kidney, they are more prevalent in neural and muscular tissues such as the brain, eye, skeletal muscles and cardiac muscles. They are called true cysts because the cyst wall is composed of parasitic material. True cysts are formed against the developing immunity of the infected person. The organisms within are called bradyzoites (slow dividing zoites), (3) Oocysts these are found in the small intestine of the definitive host ( domestic cats and other felines) and are passed in the faeces of the infected animals. Each cyst contains two sporocysts. On reaching the external environment the oocysts undergo process of

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maturation called sporulation. A sporulated oocyst will have two spotocysts each containing four sporozoites LIFE CYCLE In the definitive host (cat) there are two cycles of development- enteroepithilial and extraintestinal. In the intermediatel or accidental hosts such as humans and all other animals there is only an extra-intestinal phase of development. Sexual and asexual multiplication of Toxoplasma occurs in the enerocytes of cats and lead to excretion of oocysts in their faeces. Sporulation (formation of sporozoites) takes place in outside environment within 3 -4 days. The oocyst is resistant and survives in the environment for at least one year. In the intermediate host ( human, cattle, goats) the ingested oocysts rupture in the small intestine liberating the sporozoites.These enter the mononuclear cells to form pseudocysts. With the development of immunity the organisms enter tissues to form true cysts. These cysts do not elicit an immune response in the host and remain in the infected cells for life kept in check by the host immunity. However, if the immunity is suppressed or lost they get reactivated to resume the acute phase. There is no intestinal development cycle in the intermediate hosts. True cysts containing tachyzoites found in meat animals can transmit the infection to others when infected meat is eaten un or undercooked.

3 oocysts . Oocysts transform into tachyzoites shortly after ingestion. These tachyzoites localize in neural and muscle tissue and develop into tissue cyst bradyzoites . Cats become infected after consuming intermediate hosts harboring tissue cysts . Cats may also become infected directly by ingestion of sporulated oocysts. Animals bred for human consumption and wild game may also become infected with tissue cysts after ingestion of sporulated oocysts in the environment eating undercooked meat of animals harboring tissue cysts .
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Pathogenesis: Tachyzoites divide forming an intracellular pseudocysts leading to cellular disruption. Released tachyzoites invade adjacent tissues. Eventually tissue cysts form, containing quiescent bradyzoites.The acute phase can cause mild illness in the immunocompetent but causes severe disease in the immunocompromised host such as in AIDS. The chronic phase is asymptomatic and remains so unless the immunity is lost. T. gondii is one of the few parasites that can cross the placenta to infect the foetus and this occurs only in the acute phase with the tachyzoites. Infection in utero is uncommon but has serious effects on the foetus. Clinical features: In immunocompetent patients mild illness, cervical lymphadenopathy with fever Congenital toxoplasmosis The features of congenital toxoplasmosis range from a severely damaged infant, with death in the utero, to an infected but clinically unaffected child. Severe congenital toxoplasmosis occurs in only 10 % of infected infants and are present with hydrocephalus, mental retardation, cerebral calcification, retinochoroiditis. Ocular toxoplasmosis-ocular defects Diagnosis:: Isolation: Parasite can be isolated in culture by inoculation of infected specimens and identified on its morphology. Parasite detection: Histological examination of excised lymph nodes or biopsy of a brain lesion in AIDS Antigen detection by ELISA Parasite DNA detection by PCR Serology: Serology is often the investigation of choice. In most instances diagnosis is made on the results of these tests. (1.) Sabin-Feldman dye test- The dye test developed by Sabin and Feldman is the longest established serological method and represent the gold standard (2) Indirect haemagglutination test (3) Indirect fluorescent antibody test. (4) ELISA- Specific IgM, IgA or low avidity IgG is associated with more recent infection. Diagnosis of congenital infections
can be achieved by detecting T. gondii DNA in amniotic fluid using molecular methods such as PCR CT and MRI scan useful in patients with congenital toxoplasmosis and AIDS .

Transmission: Humans can get infected with Toxoplasma gondii by any of the following methods
consuming food or water contaminated with cat faeces or by contaminated environmental samples (such as faecal-contaminated soil or changing the litter box of a pet cat). blood transfusion or organ transplantation transplacentally from mother to fetus

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Prevention: Measures such as avoidance of close contact with cats and contaminated soil especially during pregnancy, washing hands after gardening and eating well cooked meats helps to limit infection. Pet cats should be fed with cooked food to minimize hunting for food. Cat faeces should be disposed hygienically. Sarcosporidiosis This parasitic infection is caused by several species of Sarcocysts which are coccidian parasites with two host life cycles. Herbivores and humans may act as intermediate hosts with parasites in skeletal and cardiac muscles. Humans, dogs and other carnivores are thought to be the definitive hosts with a parasitic lifecycle in the intestinal epithelium. In muscle and connective tissues of humans and animals affected as intermediate hosts, the parasites are found as zoites. They are crescentic shape. Zoites are found within cysts known as Meichers tubes . Cysts in the muscles can cause myositis and muscle necrosis. Several human infections have been reported from Africa, Central America and South East Asia. No human cases have been reported in Sri Lanka. Exercise based on the topic 1. Describe the pathogenesis of toxoplasmosis 2. Describe the transmission of toxoplasmosis to humans 3. Describe the laboratory diagnosis of toxoplasmosis

Dr. DI/Para